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Wednesday, June 10, 2009

When EBM is not enough...

I recently had my third child (he's 7 weeks today) and he's a boy - which is a new experience since my two others are girls. Among the various new challenges (which include changing diapers - I've managed to get sprayed on more than one occasion) one unanticipated challenge is what to do with the vaccination schedule? Since my 2 older children are girls, I didn't really worry about autism - but now that I have a son, I find others are asking what I will do?

Well, I started to answer this question with my EBM skills - I looked up the evidence to support any change in the normal practice and of course, there is no good evidence right now. However, now that I have engaged my many Mom friends on this topic, I have heard many, many anecdotes of parents who are sure that a known case of autisum was related to the vaccines given all at once.

Next week, my little one is schedule to get 5 vaccines at once - 4 injected and 1 oral. With all due respect to EBM, while there's no good evidence to support any interventions, I've decided to give the vaccines over 2 visits, probably 1-2 weeks apart. I figure there's little to lose and possibly something to gain? At the very least I wont' have to sit there and watch him scream 4 times - on the other hand, I'll have to take a crying baby home on 2 different days...

19 comments:

There is no evidence to support splitting up the vaccines. There is no evidence to support causality between vaccines and autism. Autism can present around the time that some of the vaccines are given. The 1998 study that proposed a link was falsified and has been discredited multiple times. See http://www.cdc.gov/vaccinesafety/concerns/mmr_vaccine.htm

I have given all 4 of my children the vaccines as recommended... and yes, at times, they have rec'd up to 5 vaccines in a sitting. However, as a pediatrician, i don't see a problem w/ splitting the vaccines into 2 visits. The important thing is that the child get the vaccines to prevent the illnesses, not the timing. So I say, do what feels right regarding the timing of the vaccines.

As to your thought that many of your mom friends are convinced that autism is connected to vaccines, I have to disagree. When a mother tells me something is wrong w/ her child, I take her very seriously. But there is a phenomenon I'll call "Mom knowledge" which is what happens when a group of mothers become convinced of something regardless of what evidence is shown. This is not just Moms, but any group of people suffering from an illness that is ill-defined and not easily explained (i.e. fibromyalgia, IBS). I would take Mom-knowledge w/ a grain of salt. For instance, Mom-knowledge used to state that it was better for newborns to sleep face down so they wouldn't choke on their spit-up. We now know that it is a major cause of SIDS.

Dr Robert Sears discusses an alternate vaccination schedule in his excellent book "The Vaccine Book". He's pro-vax and has really gone out of his way to shed light (where he can - in some places there are just no good studies to support or deny claims) on all the issues surrounding vaccination.

My doc suggested we delay six months for the vaccines, which is our plan. I'm still nervous, but feel like that's at least a good balance.

I've done respite care for an autistic child whose mother is convinced it was the vaccine, so I know your hesitancy. But I've also watched my father suffer with whooping cough, which led to permanent damage.

Well, is there really anything in the literature that shows that giving all the vaccines at once is as safe/safer than splitting them up? I seriously doubt it--all that can be said is that there is no evidence that it is dangerous. Totally different things, in my book.

My family is in what I hope is the rare and certainly the unenvienable position of having seen the damage that a disease that can be prevented by vaccine can do as well as seeing the damage that a vaccine can do. My aunt had typhoid at age two and was left hemiplegic, mentally retarded and with seizures. She lived until she was 66. My niece was left with an intractable seizure disorder after she received the whole-cell pertussis vaccine at age 3 months. She died just before her 25th birthday, 4.5 years ago.

We chose to selectively vaccinate our children, and even so, our daughter ran very high fevers after two of her DT vaccines. She has chosen not to have her son (20mo) receive any vaccines.

I believe that deciding about vaccines is one of the hardest decisions that parents have to make, mainly because it is not a one time decision, but one that has to be constatnly revisited as the child gets older, as the family history may change, as potential exposure may change due to travel plans or an outbreak in the community and many other factors.

Personally, I think two days of vaccine-cranky baby is worse than one, but probably worth it if it gives you peace of mind. I personally don't believe splitting vaccines does anything to prevent autism... but that's not to say that I haven't considered it.

There is quite literally no scientific evidence that vaccines cause autism. The Autism Omnibus presented their three best cases to the Vaccine Court, and they were all thrown out. Many large studies have been conducted to look at links between the two, and nothing has been found: see a summary here. Researchers have taken these concerns very seriously indeed. What's worse, Andrew Wakefield, who published the original evidence linking the MMR and autism, has been discredited so thoroughly it's not even funny (massive conflict of interest, cooked data, small sample, crap laboratory, study results have not been replicated by independent researchers who used a similar design with more participants)

Dr Sears' alternative schedule is not based on any science. If he gets people to vaccinate at all, more power to him, but he doesn't seem to get why the current schedule is sound.

The reason vaccines and the MMR are linked is that the MMR is given at a time in children's development where autism starts to become obvious to parents. However, signs are often apparent far earlier, but aren't noticed / interpreted correctly.

I'm a mom of an autistic son, and I just had another boy. He'll be fully vaccinated on schedule, because a) it's a good practice to vaccinate, and b) we absolutely don't believe the vaccines had anything to do with older son's autism. Wakefield's study has been so thoroughly discredited that I'm appalled that "Mom-knowledge" still thinks this is the issue. Of course, it doesn't help that Jenny from MTV still trumpets that, and she has a much larger audience than our little blog. *sigh*

What about efficacy questions of splitting vaccines by just a week or 2? I recall the Red Book stating something about vaccines not being as effective unless spread over a month or more, presumably because the immune response to vaccine #1 will mean that vaccine #2 only a week later will get a less robust response?

I think it's pretty sad when the research and medical community think that what happens in a laboratory is more real than actual human experience. When we start discrediting mothers and children because 'research' says so, then perhaps we need to question our societal values.

This is a highly controversial topic, and being Med Peds, once that I struggle with every day with parents. At the end of the day, you just have to do what you feel is right for your child.

If you want to talk EBM, then what we know is that there is no evidence that autism is caused by vaccines. The current vaccination schedules are studied before they are proposed, and there is no need for any alternate schedules. The vaccines aren't any less effective doing them together, and delaying vaccination can allow for vaccine preventable disease to set in. Since you are into EBM, I would recommend for you to read the CDC website. I think it's much more evidence based than Dr. Sears' book.

My daughter (now 9) was vaccinated on schedule, although I waited on varicella because I was concerned about duration of immunity. When it was required by the school district, I did it immediately.

I am extremely cynical/suspicious about Big Pharma - I don't see reps, I never prescribed COX-2 inhibitors (and I mean never) and I counter-detail my partners and my patients so often they complain about it. I won't use any drug-company advertising (no, not even pens) and I won't eat the food the reps bring into the office. So I'm not exactly a tool of the drug companies (who don't make a whole lot of money off vaccines, anyway), but whenever I post in a public forum supporting immunization, that's the accusation that's leveled at me.

I'm also the daughter of a polio survivor.

I'm not aware of any evidence of harm from delaying some of the vaccines; I know the current schedule is designed in part to make sure that parents with limited access can get as many immunizations as possible. You're far more likely than most parents to actually complete the schedule if you do it differently, and I support your right to do so, but would not recommend that as a standard.

I've more to say but this is long enough...guess I should post something at my own blog.

I don't have kids, but when I was a baby the health care system I grew up under (some western European country) did not prescribe many of the vaccines in the early 80's that are now on the regular vaccine schedule. The only vaccines I got as a baby were BCG, Diptheria, Tetanus, Pertussis (all separate) and some vaccine for a particular strain of meningitis transmitted by ticks. No MMR, no varicella, no Hep, and I got mumps, measles and the chicken pox (yes, the diseases). Mumps and the chicken pox weren't so horrible, but measles was absolutely awful and terrifying. I was out of school for 6 weeks, and spent most of that time hallucinating from high fever and trying to keep anything from touching my skin, since I didn't really have red dots, but my entire body was swollen, puffy and bright red, even between my toes and fingers.

My point is that parents hear scary (likely untrue) things about the possible effects of vaccines (autism...) and freak. They don't know what it's like to have mumps or the measles, and I believe that they need to be told about these diseases so they can make an informed decision about which is the lesser evil.

My possible, future children will get a full course of standard vaccines, and I'm happy to report that I was caught up on all the "regular" vaccines as a young adult, because grad school's admission committee said vaccines or else...

Thank you for all your thoughts on this...I'm so glad I asked for advice. I'm definitely still feeling post-partum and emotional about things I don't usually react to - your comments are helping me sift through emotion vs. data.

I think I'll stick to the recommended exam schedule.

And while I had not clearly acknowledged the phenomena of 'mom knowledge' - I must agree that it's a powerful force and one that needs to be recognized and taken in stride. I seem to hear more of it now that I'm on maternity leave:)

I also need to say that I learned a few things reading all your comments - proof that every question is worth asking. I was hesitating at first thinking that as a physician I should already have an answer to this, but remembered that I always tell my students to never hesitate to ask questions...and proof of point - I asked and I learnt.

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